30 unit 1 | Professional Considerations
In the case Tovar v. Methodist Healthcare(2005), a
75-year-old female client came to the emergency
department complaining of a headache and weakness
in the right arm. Although an order for admission to
the neurological care unit was written, the client was
not transported until 3 hours later. After the client
was in the unit, the nurses called one physician
regarding the client’s status. Another physician
returned the call 90 minutes later. Three hours later,
the nurses called to report a change in neurological
status. A STAT computed tomography scan was
ordered, which revealed a massive brain hemorrhage.
The nurses were cited for the following:
- Delay in transferring the client to the neurolog-
ical unit - Failure to advocate for the client
The client presented with an acute neurological
problem requiring admission to an intensive care
unit where appropriate observation and interven-
tions were available. A delay in transfer may lead to
delay in appropriate treatment. According to the
ANA standards of care for neuroscience nurses
(2002), nurses need to assess the client’s changing
neurological status accurately and advocate for
the client. In this instance, the court stated that the
nurses should have been more assertive in attempt-
ing to reach the physician and request a prompt
medical evaluation. The court sided with the family,
agreeing with the plantiff ’s medical expert’s conclu-
sion that the client’s death was related to improper
management by the nursing staff.If a Problem Arises
When served with a summons or complaint, peo-
ple often panic, allowing fear to overcome reason.
First, simply answer the complaint. Failure to do
this may result in a default judgment, causing
greater distress and difficulties.
Second, many things can be done to protect
oneself if named in a lawsuit. Legal representation
can be obtained to protect personal property. Never
sign any documents without consulting the mal-
practice insurance carrier or a legal representative.
If you are personally covered by malpractice insur-
ance, notify the company immediately, and follow
their instructions carefully.
Institutions usually have lawyers to defend
themselves and their employees. Whether or not
you are personally insured, contact the legal depart-
ment of the institution where the act took place.
Maintain a file of all papers, proceedings, meetings,box 3-2
Some Documentation Guidelines
Medications:- Always chart the time, route, dose, and response.
- Always chart PRN medications and the client response.
- Always chart when a medication was not given, the reason (e.g., client in Radiology, Physical Therapy; do not chart that the
medication was not on the floor), and the nursing intervention. - Chart all medication refusals, and report them.
Physician communication: - Document each time a call is made to a physician, even if he or she is not reached. Include the exact time of the call. If the
physician is reached, document the details of the message and the physician’s response. - Read verbal orders back to the physician, and confirm the client’s identity as written on the chart. Chart only verbal orders
that you have heard from the source, not those told to you by another nurse or unit personnel.
Formal issues in charting: - Before writing on the chart, check to be sure you have the correct patient record.
- Check to make sure each page has the client’s name and the current date stamped in the appropriate area.
- If you forgot to make an entry, chart “late entry,” and place the date and time at the entry.
- Correct all charting mistakes according to the policy and procedures of your institution.
- Chart in an organized fashion, following the nursing process.
- Write legibly and concisely, and avoid subjective statements.
- Write specific and accurate descriptions.
- When charting a symptom or situation, chart the interventions taken and the client response.
- Document your own observations, not those that were told to you by another party.
- Chart frequently to demonstrate ongoing care, and chart routine activities.
- Chart client and family teaching and their response.